2.1

Compared to surgical abortion, which of the following is increased in a woman undergoing a medical abortion?

blood loss

A 23-year-old G0 woman with last menstrual period 14 days ago presents to the office because she had unprotected intercourse the night before. She does not desire pregnancy at this time and is requesting contraception. She has no medical problems and is not taking any medications. In addition to offering her counseling and testing for sexually transmitted infections, which of the following is the most appropriate next step in the management of this patient?

Emergency contraception, then begin OCPs

A 38-year-old G0 woman comes to the office for a health maintenance examination. She is healthy and not taking any medications. She has no history of abnormal Pap tests or sexually transmitted infections. Her menstrual cycles occur monthly with mild cramping. Her mother was diagnosed with endometriosis and had a hysterectomy and removal of the ovaries at age 38. She is 5 feet 4 inches tall and weighs 130 pounds. On pelvic examination, the patient has a palpable and mildly tender left adnexal mass. An ultrasound was obtained, which showed a 4 cm left ovarian cyst that has an echogenic but homogeneous "ground glass" appearance. What is the most likely diagnosis in this patient?

Endometrioma

Which of the following is a contraindication for manual vacuum aspiration of this patient?

Gestational age

A 21-year-old G0 woman complains of vulvar itching. She reports that she has recently started a new relationship with her girlfriend. She reports that both she and her partner are monogamous, and neither have a history of sexually transmitted infections. They practice safer sex and have been using a dental dam. On physical exam, a poorly demarcated erythematous rash with edema is present involving most of the labia. Which of the following is the next best step in the management of this patient?

Discontinue use of dental dam

A 16-year-old G0 female presents to the Emergency Department with a two-day history of abdominal pain. She is sexually active with a new partner and is not using any form of contraception. She denies any history of painful urination. Temperature is 102.0°F (38.9°C). On examination, she has lower abdominal tenderness and guarding. On pelvic exam, she has diffuse tenderness over the uterus and bilateral adnexal tenderness. Beta-hCG is less than 5. What is the most likely diagnosis for this patient?

Acute salpingitis

A 32-year-old G3P1 woman is concerned about an exposure to hepatitis B. She had vaginal and anal intercourse with a new partner three days ago and did not use condoms. The partner informed her today he was recently diagnosed with acute hepatitis B acquired from intravenous drug use and needle sharing. She has no prior history of hepatitis B infection and has not been vaccinated. She is currently asymptomatic and her examination is normal. Her urine pregnancy test is negative. What is the next best step in the management of this patient?

Administer HBIG and Hep B vaccine

What is the strongest predictor of post-sterilization regret for this patient?

Age

A 20-year-old G0 woman presents with a one-month history of profuse vaginal discharge and mid-cycle vaginal spotting. She uses oral contraceptives and thinks her irregular bleeding is due to the pill. She is sexually active and has had a new partner within the past three months. She reports no fevers or lower abdominal pain. She has otherwise been healthy. On pelvic examination, a thick yellow endocervical discharge is noted. Saline microscopy reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide testing is negative. Vaginal pH is 4.0. No cervical motion tenderness or uterine/adnexal tenderness is present. Testing for gonorrhea and chlamydia is performed, but those results will not be available for several days, and she is leaving for Europe tomorrow. Which of the following is the most appropriate treatment for this patient?

Azithromycin and doxy

Which of the following treatments is the next best step for emergency contraception?

Copper IUD

A 24-year-old G2P1 woman who underwent an elective termination two days ago presents to the emergency room with abdominal and pelvic pain. She has been feeling nauseated and reports a fever at home. On presentation, her blood pressure is 100/60, pulse 100 beats/minute, respiration 16/minute; temperature 102°F (38.9°C). Physical examination reveals diffuse abdominal tenderness, and on pelvic examination, she has marked cervical motion tenderness. Ultrasound shows an 8- mm endometrial stripe. In addition to sending a CBC and cultures, which of the following is the most appropriate next step in the management of this patient?

Begin IV antibiotics

A 25-year-old G1P1 woman presents to the office with a one day history of left breast pain and fever. She is breastfeeding her 2- week-old infant. . Her vital signs are: blood pressure 120/60; pulse 64 beats/minute; temperature 99.9° F (37.7° C). On exam, she has erythema on the upper outer quadrant of the left breast, which is tender to touch. There are no palpable masses. In addition to starting oral antibiotics, what is the most appropriate next step in the management of this patient?

Begin ibuprofen

A 32-year-old G4P4 desires contraception. She reports that she and her husband no longer desire to have children. Her past medical history is signficant for being positive for BRCA 1. She has previously been on a progestin-only pill, but doesn't like taking a pill everyday. Which of the following contraceptive methods is the most appropriate for this patient?

Bilateral salpingectomy

A 24-year-old woman complains of cyclic mastalgia since the onset of her period at age 12. The symptoms have increased over the years but were less troublesome when she took oral contraceptives a few years ago. Currently, she takes no medications and is not sexually active. She is a strict vegetarian and eats soy products. She does not smoke, and drinks three glasses of wine per week and several diet colas every day. Her mother was diagnosed with breast cancer at age 55. Her breast exam is normal, except for some mild fibrocystic changes. Which of the following elements in her history contributes to her increasing pain?

Caffeine intake

A 33-year-old G3P3 woman presents to the office complaining of a new onset vaginal discharge of four days duration. The discharge is thick and white. She has noted painful intercourse and itching since the discharge began. Her vital signs are blood pressure 120/76 and pulse 78 beats/minute. The pelvic examination reveals excoriations on the perineum, thick white discharge, and is otherwise non-contributory. What is the most likely diagnosis in this patient?

Candida

A 33-year-old G0 woman presents for a Loop Electrosurgical Excision Procedure (LEEP). She was recently married. She and her husband desire to have children in the near future. She had a Pap test four weeks ago that showed HSIL followed by a colposcopy with a directed biopsy confirming CIN III. Her endocervical curettage was negative for dysplasia. Prior to her procedure, informed consent is obtained. Of the following complications, which is specific to this procedure?

Cervical stenosis

A 23-year-old woman presents with complaints of a bilateral nipple itchy sensation for six months. There is no nipple discharge or dry skin. She reports her nipple appears to be swollen at times and there is an erythematous fine rash. She had breast implants placed five years ago, but otherwise has no significant medical problems or surgical history. What is the most likely cause of her symptoms?

Chemical irritant

A 42-year-old G2P2 woman presents with a two-week history of a thick, curdish white vaginal discharge and pruritus. She has not tried any over-the-counter medications. She is currently single and not sexually active. Her medical history is remarkable for recent antibiotic use for bronchitis. On pelvic examination, the external genitalia show marked erythema with satellite lesions. The vagina appears erythematous and edematous with a thick white discharge. The cervix appears normal and the remainder of the exam is unremarkable except for mild vaginal wall tenderness. Vaginal pH is 4.0. Saline wet prep reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide prep shows the organisms. Which of the following is the most appropriate treatment for this patient?

Clotrimazole

A 90-year-old G7P7 woman presents with severe vaginal prolapse. The entire apex, anterior and posterior wall are prolapsed beyond the introitus. She is not sexually active. She cannot urinate without reduction of the prolapse. Hydronephrosis is noted on ultrasound of the kidneys and thought to be related to the prolapse. She has a long- standing history of diabetes and cardiac disease. She has failed a trial of pessaries. Which of the following is the next best step in the management of this patient?

Colpcleisis

A 24-year-old G1P1 woman comes to the office requesting contraception. Her past medical history is unremarkable, except for a family history of ovarian cancer. She denies alcohol, smoking, and recreational drug use. She is in a monogamous relationship. She wants to decrease her risk of ovarian cancer. Of the following, what is the best method of contraception for this patient?

Combined oral contraceptives

A 67-year-old G3P3 woman presents with vaginal bulge. She underwent an abdominal hysterectomy several years ago secondary to endometrial hyperplasia. She denies any incontinence. She failed conservative management with a pessary. As a result, she underwent a vaginal surgical repair where the pubocervical fascia was plicated in the midline, as well as laterally to the arcus tendineus fascia (white line). What defect was repaired in this patient?

Cystocele

23-year-old G1P0 woman at six weeks gestation undergoes a medical termination of pregnancy. One day later, she presents to the emergency department with bleeding, soaking more than a pad per hour for the last five hours. Her blood pressure on arrival is 110/60, pulse is 86 beats/minute. On exam, her cervix is 1 cm dilated with active bleeding. Hematocrit on arrival is 29 percent. An ultrasound shows echogenic material in the uterine cavity. Which of the following is the most appropriate next step in the management of this patient?

D&C

A 19-year-old G2P0 woman at 20 weeks gestation presents for an elective termination of pregnancy. She is in good health and is not taking any medications. She previously had a medical termination. She expresses her desire to start contraception to prevent further pregnancies. Which of the following is the best next step in her management?

D&E and IUD placement

A 35-year-old G3P3 woman requests contraception. Her youngest child is nine months old. Her periods have been regular since she discontinued breastfeeding five months ago. Her past medical history includes depression, which is controlled with antidepressants, and a history of deep venous thrombosis. She denies smoking or alcohol use. In the past, oral contraceptive pills have caused her to have severe gastrointestinal upset. What in her history makes her an ideal candidate for progestin- only pills?

DVT

A 28-year-old G0 woman returns for a follow-up visit regarding suspected endometriosis. She has been using NSAIDs and oral contraceptive pills (OCPs) to help manage her pelvic pain. Her pain occurs throughout the month with cyclic exacerbations, which have been getting worse. Her exam is normal, with a normal sized non-tender uterus and no adnexal enlargement or tenderness. Which of the following is the next best step to confirm the diagnosis?

Dx laparoscopy

A 26-year-old G2P2 woman presents with urinary urgency and dysuria for the past three days. She has a history of a urinary tract infection once. She is sexually active and uses condoms for contraception. She is otherwise healthy and does not take any medications or supplements. She does not have fever, chills, flank pain, or vaginal discharge. Which of the following organisms is the most likely cause of this patient's symptoms?

E coli

A 50-year-old G3P3 woman comes to the office reporting heavy periods, spotting between menses, fatigue and weakness. Over the past six months, she has noticed a significant increase in the amount of her menstrual bleeding, currently requiring a box of 30 pads for each month. She has noticed an increase in the amount of blood clots and cramping pain during menses. Her previous history is significant for hypertension for 10 years, controlled with hydrochlorothiazide and a postpartum bilateral tubal ligation 20 years ago. She has no history of abnormal Pap tests and no sexually transmitted infections. Blood pressure is 138/84; pulse, 82; respirations, 20; weight, 220 pounds; height, 5 feet, 8 inches. On pelvic exam, uterus is approximately 10-week size. She is non- tender on bimanual exam and no adnexal masses are appreciated. A Pap test one month ago was normal, hematocrit is 29 and she is asymptomatic. What is the next best step in the management of this patient?

Endometrial bx

A 27-year-old G0 woman presents with a one-year history of dysmenorrhea and dyspareunia. Pain, when present, is 7/10 in strength and requires that she miss work. She now avoids intercourse and no longer finds it pleasurable. She is in good health and is not taking any medications. Her last menstrual period was 17 days ago and her menses are typically 28 days apart. She had chlamydia once, at age 19. Physical examination is notable for mild tenderness on abdominal examination in the lower quadrants, and bilateral adnexal tenderness on pelvic examination. Uterus is normal in size and there is uterosacral ligament nodularity. What is the most likely diagnosis in this patient?

Endometriosis

A 28-year-old G0 woman presents for preoperative counseling. She has a suspected diagnosis of severe endometriosis and has failed conservative medical management with oral contraceptive pills. Her symptoms include severe pelvic pain especially prior to and during menstruation, and deep dyspareunia. On pelvic examination, she has uterosacral nodularity and tenderness throughout both adnexa. Ultrasound reveals normal ovaries bilaterally. Which of the following procedures is the best option for this patient?

Excision of endometriosis implants

A 34-year-old G2P2 woman, who recently underwent colposcopy with biopsy following a Pap test that showed low-grade squamous intraepithelial lesion, comes in to discuss her results. The biopsy results showed CIN III. Endocervical curettage showed benign endocervical cells. What is the most appropriate next step in the management of this patient?

LEEP

A 54-year-old woman presents with a breast mass she noticed two months ago. She has no family history of breast cancer. On exam, there is a 2 cm mass palpable in the upper outer quadrant of the left breast. There are no other masses noted and no palpable lymphadenopathy. A fine needle aspiration returns bloody fluid and reduces the size of the mass to 1 cm. In addition to obtaining a mammogram, what is the most appropriate next step in the management of this patient?

Excisional bx

A 42-year-old G1P1 woman presents to the office with a breast mass. She noticed a mass on her right breast during a self-breast exam two months ago. She has not noticed nipple discharge or skin changes. The mass has not changed in size. Her review of systems is negative. She does not use tobacco, alcohol or drugs, and she drinks five cans of caffeinated soda per day. She has a maternal aunt with breast cancer who was diagnosed at age 50. On examination, the left breast is normal; right breast has a 1 cm x 2 cm rubbery mobile mass in the upper outer quadrant. There was no nipple discharge, no visible skin changes and no axillary or supraclavicular lymphadenopathy. A mammogram three months ago was normal and showed dense breast tissue bilaterally. Of the following, what is the best next step in the management of this patient to help determine her diagnosis?

FNA

A 50-year-old G0 presents to the office for an annual exam. She has no complaints and still has regular menses. Her past medical history is significant for lymphoma at age 22, and she is status post chest wall irradiation without evidence of recurrence. Her family history is significant for an older sister who developed breast cancer at age 61. On exam, you palpate a 1 cm mobile, slightly tender, cystic mass in the left breast in the upper outer quadrant. In addition to mammography, which of the following factors would be an indication for breast MRI?

Family history

A 23-year-old G0 woman presents with a three-day history of a painful nodule in her axilla. She is healthy and has no personal or family history of breast disease. On exam, no abnormalities are seen on inspection and no breast mass is palpated. In the axillary area, shaved skin is noted and an erythematous raised 1 cm lesion is palpated and is slightly tender to touch. What is the most likely diagnosis?

Folliculitis

A 32-year-old G1P1 is concerned about pelvic organ prolapse at her postpartum visit because her friend has had signficant complications requiring surgical interventions. Her past medical history is significant for hypothyroidism and type 2 diabetes. Her obstetric history was complicated by the need for a forceps assisted vaginal delivery for fetal indications after pushing for two hours. Her blood pressure is 120/80, pulse is 67 beats/minute, BMI 22 kg/m2. Given her history, which of the following puts her at greatest risk for pelvic floor prolapse?

Forceps delivery

A 26-year-old G2P2 woman presents with a new onset of vulvar burning and irritation. She is sexually active with a new male partner. She is using oral contraception for birth control and did not use a condom. She thought she had a cold about 10 days ago. Which of the following is the most likely diagnosis in this patient?

HSV

A 30-year-old G2P0 woman presents with a complaint of worsening dysmenorrhea. Her periods occur regularly every 28 days, but she experiences severe central cramping pain in the week preceding and during her menses. Her gynecologic history is notable for chlamydia infection at age 19, and cervical dysplasia at age 25. Two years ago, she underwent a LEEP procedure that resulted in cervical stenosis. Her medical history is notable for Hodgkin's lymphoma at age 21, treated with doxorubicin and bleomycin. Her family history is notable for a maternal aunt with ovarian cancer. Which of the following is a risk factor for her to have endometriosis?

Hx of LEEP procedure

A 30-year-old G0 woman comes to the office because she desires removal of her IUD. She had a copper intrauterine device placed for contraception four years ago, and now she desires pregnancy. She is in good health and has no history of abnormal Pap tests or sexually transmitted infections. Pelvic exam shows a normal appearing cervix and no IUD string visible. Ultrasound shows the IUD in the uterine cavity. An attempt is made to remove the IUD with an IUD hook and failed. What is the most appropriate next step in the management of this patient?

Hysteroscopy

A 20-year-old G2P2 healthy woman presents for her postpartum check six weeks after a full-term normal spontaneous delivery. She has a 13-month-old in addition to the six-week infant, and is already feeling overwhelmed. She desires a reliable form of contraception. On exam, her vital signs are normal. BMI is 35 kg/m2. The remainder of the exam is unremarkable. Of the following, what is the most effective and appropriate form of contraception for this patient?

IUD

A 17-year-old G0 female presents to the Emergency Department with pelvic pain that began 24 hours ago. She is currently sexually active with her boyfriend. She has been experiencing nausea and vomiting, and cannot tolerate any oral intake. She reports menarche at the age of 15 and coitarche soon thereafter. She has had four male partners, including her new boyfriend of a few weeks. Her blood pressure is 100/60, pulse 100 beats/minute, and temperature 102.0°F (38.9°C). On speculum examination, you note a foul-smelling mucopurulent discharge from her cervical os, and she has significant tenderness with manipulation of her uterus. What is the next best step in the management of this patient?

Inpatient treatment and IV antibiotics

A 24-year-old nulligravid woman has been trying to conceive for the past 18 months. She has experienced moderate dysmenorrhea for years, and notes deep dyspareunia during coitus. Her periods come regularly every 28 days. She is on no medications other than naproxen at the time of her menses. Examination demonstrates a normal sized uterus with some mild tenderness in the posterior cul-de-sac, and normal adnexae. Which of the following treatments is recommended to help her conceive?

Laparoscopy

A 21-year-old trans man desires to begin contraception. He has chosen to retain his uterus and ovaries for future childbearing. His past medical history is negative. His past surgical history is significant for breast implants. He denies smoking, use of recreational drugs, and excessive drinking. He currently takes testosterone daily. Which of the following is the best form of contraception for this patient?

Levonorgesterol IUD

A 16-year-old female is experiencing excessive genital itching. She reports that her symptoms started about 3 weeks ago. Her past medical history is negative. She is currently sexually active with her boyfriend. She reports use of tobacco and occassionally heroin. Her blood pressure is 120/80, pulse 89 beats/minutes, BMI is 16 kg/m2. Her exam reveals small black powder like substance on her pubic hair. Which of the following is the most likely cause of her symptoms?

Lice

A 52-year-old G0 woman presents with long-standing vulvar and vaginal pain and burning. She has been unable to tolerate intercourse with her husband because of pain at the introitus. She has difficulty sitting for prolonged periods of time or wearing restrictive clothing because of worsening vulvar pain. She recently noticed that her gums bleed more frequently. She avoids any topical over-the-counter therapies because they intensify her pain. Her physical examination is remarkable for inflamed gingiva and a whitish reticular skin change on her buccal mucosa. A fine papular rash is present around her wrists bilaterally. Pelvic examination reveals white plaques with intervening red erosions on the labia minora as shown in the picture. A speculum cannot be inserted into her vagina because of extensive adhesions. The cervix cannot be visualized. Which of the following is the most likely diagnosis in this patient?

Lichen Plans

A 64-year-old G2P2 woman presents with a 12-month history of severe vulvar pruritus. She has applied multiple over-the-counter topical therapies without improvement. She has no significant vaginal discharge. She has severe dyspareunia at the introitus and has stopped having intercourse because of the pain. Her past medical history is significant for allergic rhinitis and hypertension. External genitalia is shown in the picture. No ulcerations are present. The vagina is mildly atrophic, but appears uninvolved. Which of the following is the most likely diagnosis in this patient?

Lichen sclerosis

A 22-year-old transman presents with a vaginal discharge. He notes that this has been present for the past week. He is currently sexually active with his male partner. Current medications include testosterone, and he has a levonorgesterol IUD for contraception and control of uterine bleeding. His past surgical history is significant for breast implants. Physical exam reveals a watery, gray discharge. Wet prep shows clue cells. What is the next best step in his management?

Metronidazole

A 32-year-old G0 woman with a last menstrual period three weeks ago presents with a three-month history of a malodorous vaginal discharge. She reports no pruritus or irritation. She has been sexually active with a new partner for the last four months. Her past medical history is unremarkable. Pelvic examination reveals normal external genitalia without rash, ulcerations, or lesions. Some discharge is noted on the perineum. The vaginal exam reveals only a thin, gray homogeneous discharge. The vaginal pH is 5.0. A wet prep is shown in the image below. Which of the following is the most appropriate treatment for this patient?

Metronidazole

A 60-year-old G4P4 woman presents with a two-year history of urine leakage with activity such as coughing, sneezing and lifting. Her past medical history is significant for two vaginal deliveries of infants greater than 9 pounds. She had a previous abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine fibroids. She is on vaginal estrogen for atrophic vaginitis. Physical examination reveals no anterior, apical or posterior wall vaginal prolapse. The vagina is well-estrogenized. Post-void residual is normal. Q-tip test shows a straining angle of 60 degrees from the horizontal. Cough stress test shows leakage of urine synchronous with the cough. Cystometrogram reveals the absence of detrusor instability. The patient failed pelvic muscle exercises and is not interested in an incontinence pessary. Which of the following is the best surgical option for this patient?

Mid urethral sling

A 23-year-old G1P0 woman at seven weeks gestation presents for pregnancy termination. On exam, her blood pressure is 120/80, heart rate is 67 beats/minute, and she is afebrile. Her cervix is closed, and there is no evidence of bleeding. She desires to have the least invasive treatment possible. Which of the following options is best for this patient?

Mifeprostone and misoprostol

The gynecologist on call is summoned to the operating room for an intraoperative consult. A 45-year-old woman is there having a laparoscopic cholecystectomy performed by the general surgeon. During the procedure, he examined the pelvis and incidentally noted powder burn lesions in the rectovaginal pouch and uterine surface that look like endometriosis. The patient had no pelvic complaints prior to surgery. She had previously undergone a tubal ligation. She has no family history of gynecological or colon cancer. Assuming that the patient's surgical consent covered any necessary treatment, what is the proper course of action for the consultant?

No further intervention

A 26-year-old G0 woman returns for a follow-up visit regarding endometriosis. She has been using naproxen to manage her pelvic pain, but had to miss four days of work in the last two months. She is sexually active with her husband of two years, although it has been more painful recently. She has regular menstrual cycles and is using condoms for contraception. On pelvic examination, she has localized tenderness in the cul-de-sac and there are no palpable masses. What is the most appropriate next step in the management of this patient?

OCPs

A 56-year-old G3P3 woman presents to the office for her annual health maintenance examination. She has been postmenopausal for three years and has no complaints. She is in good health and is not taking any medications. She had an abnormal Pap test 10 years ago, but results have been normal since. She is sexually active with her husband. On examination, her cervix is 1 cm above the vaginal introitus, and there is moderate bladder prolapse. Her uterus is normal in size, and she has no adnexal masses or tenderness. In addition to recommending a mammogram, what is the most appropriate next step in the management of this patient?

Observation

A 22-year-old G1P0 woman with LMP six weeks ago presents for elective termination of pregnancy. She is healthy with no medical problems. An ultrasound performed in the office shows an 8 mm endometrial stripe with no intrauterine gestational sac and no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?

Obtain a beta-hCG level

A 29-year-old G0 woman presents due to the inability to conceive for the last 18 months. She has a known history of endometriosis, which was diagnosed by laparoscopy three years ago. She has pelvic pain, which is controlled with non-steroidal anti-inflammatory drugs. Her cycles are regular. She is otherwise in good health and has been married for five years. Her husband had a semen analysis, which was normal. She had a hysterosalpingogram, which showed patent tubes bilaterally. She is getting frustrated that she has not yet achieved pregnancy and asks to proceed with fertility treatments. What is the most appropriate next step in the management of this patient?

Ovarian stimulation with IU insemination

A 76-year-old G3P3 woman presents with worsening urinary incontinence for the past three months. She reports increased urinary frequency, urgency and nocturia. On examination, she has a mild cystocele and rectocele. A urine culture is negative. A post-void residual is 400 cc. Which of the following is the most likely diagnosis in this patient?

Overflow incontinence

A 35-year-old G2P2 woman presents for irregular bleeding. She had a levonorgesterol IUD placed four years ago and had no bleeding until about 3 months ago. She noted that her periods have returned and she is concerned that IUD is no longer providng her contraception. She denies any pain with her periods. Her physical exam shows that her IUD strings are not visible. What is the next best step in the management of this patient?

Pelvic US

A 38-year-old G1P1 woman comes to the office for a health maintenance examination. She has noticed some urinary frequency over the past month. She has no dysuria, hematuria, urgency or incontinence. She has normal cycles, no history of abnormal Pap tests or sexually transmitted infections and is sexually active with one partner. She smokes five cigarettes daily, and drinks one glass of wine per day. Her mother had breast cancer at age 30. Her general examination is normal. On pelvic exam, she has normal external genitalia; vagina and cervix are without lesions. Her uterus is normal size, anteverted and nontender. Her left adnexa is normal, right adnexa has a mobile, slightly tender 4 cm mass. Laboratory results show a normal urinalysis, a negative urine pregnancy test and a normal Pap test. What is the most appropriate next step in the management of this patient?

Pelvic US

A 42-year-old G3P3 woman presents to the office after noticing a breast mass while performing a breast self-exam. She is in good health and has normal menstrual cycles. Physical exam is significant for a 1 cm firm, mobile, nontender breast mass. The remainder of the exam is normal. A mammogram obtained today shows no abnormalities. A fine needle aspiration was non-diagnostic, and the mass persisted. What is the most appropriate next step in the management of this patient?

Perform excision bx

An 85-year-old G3P3 woman presents with symptoms of vaginal pressure and heaviness, which seem to worsen toward the end of the day. She has a history of three vaginal deliveries. Her past medical history is significant for hypertension, coronary artery disease and a deep venous thrombosis. Her surgical history is significant for hysterectomy for abnormal uterine bleeding at age 45. On exam, she is found to have a large pelvic prolapse. Which of the following is the most appropriate initial treatment of this patient's prolapse?

Pessary fitting

A 47 year-old G3P3 woman presents to the office complaining of intermenstrual bleeding. She notes that she has always had regular periods and for the past 3 months has noted spotting in between her periods and after intercourse. She denies increased cramping with her periods. She had a normal Pap test 6 months ago with negative cytology and HPV testing. She is sexually active only with her husband. Her blood pressure is 130/80, pulse 80, respirations 20, and her BMI is 37. Her pelvic exam reveals a small fleshy mass with a stalk arising off of her cervix. She has a normal sized uterus without adnexal masses or tenderness. What is the most appropriate next step in her care?

Polypectomy

A 38-year-old G0P0 woman complains of worsening dysmenorrhea. Her menstrual cycles are regular, but increasingly painful with cramping that is unresponsive to NSAIDs. She is monogamous with her husband but notes deep dyspareunia with every act of coitus. She is otherwise healthy and uses no medications. On examination, tenderness at which of the following sites would be most consistent with a diagnosis of endometriosis?

Posterior fornix

A 36-year-old G2P2 woman presents with irregular vaginal bleeding. Six weeks ago, she had her first depot medroxyprogesterone injection, and now she has unpredictable bleeding. She is concerned by these symptoms. She has a history of hypertension but is currently on no medications. Vital signs reveal: blood pressure 130/90, weight 188 pounds, height 5 feet 5 inches, BMI 31.4kg/m2. Which of the following is the most appropriate next step in the management of this patient?

Reassurance

A 68-year-old G3P3 woman presents with breast tenderness. She is in good health and is not taking any medications. Her 70- year-old sister was recently diagnosed with breast cancer. On breast examination, her breasts have no lesions, and there are no palpable masses, nodules or lymphadenopathy. Her last mammogram was four months ago and was normal. What is the most appropriate next step in the management of this patient?

Reassurance

A 37-year-old G0 woman presents with a one-week history of a mildly painful vulvar ulcer. She reports no fevers, malaise or other systemic symptoms. She recently started use of a topical steroid ointment for a vulvar contact dermatitis. She is married and has no prior history of sexually transmitted infections. Her last Pap test, six months ago, was normal. A vulvar herpes culture later returns positive for herpes simplex virus type 2. A Rapid Plasma Reagin (RPR) is nonreactive, and HIV testing is negative. Which of the following is the most likely diagnosis in this patient?

Recurrent HSV-2

A 25-year-old G1P1 woman presents with a four-month history of a white, watery nipple discharge. She discontinued breastfeeding six months ago. Her last menstrual period was 2 weeks ago. She has been told in the past she had fibrocystic breast changes, but otherwise has no significant medical problems or surgical history. A white nipple discharge is noted on manual expression, but the exam is otherwise normal. Serum prolactin level obtained same day after exam was 45 ng/ml (normal below 40 ng/ml). What is the most appropriate next step in the management of this patient?

Repeat prolactin

A 23-year-old G2P1 woman with last menstrual period 10 weeks ago presents with lower abdominal pain and vaginal bleeding two days after undergoing an elective termination of pregnancy. Her temperature is 102.0°F (38.9°C), and the cervix is 1 cm dilated. Uterus is eight-week size and tender. There are no adnexal masses. Urine pregnancy test is positive. What is the most likely diagnosis?

Septic abortion

A 70-year-old G3P3 woman presents with a four-year history of constant leakage of urine. Her history is significant for abdominal hysterectomy and bilateral salpingo- oophorectomy for endometriosis. She had two anterior repairs in the past for recurrent cystocele. The leakage started six months after her last anterior repair. Pelvic examination reveals no evidence of pelvic relaxation. The vagina is well-estrogenized. Q-tip test reveals a fixed, immobile urethra. Cystometrogram shows no evidence of detrusor instability. Cystourethroscopy showed no evidence of any fistula and reveals a "drain pipe" urethra. Which of the following is the best first treatment for this patient?

Urethral bulking procedure

A 57-year-old G2P2 woman presents with a six-month history of urinary incontinence, urgency and nocturia. She describes the amount of urine loss as large and lasting for several seconds. The urine loss occurs when she is standing or sitting and is not associated with any specific activity. A post- void residual is 50 cc. What is the most likely cause of this patient's symptoms?

Urge incontinenence

A 32-year-old G0 woman comes to your office because she has been unable to conceive for one year. She is currently in a mutually monogamous relationship with her husband, has intercourse three times per week and has no dyspareunia. Her menstrual cycles occur every 26 to 34 days. She has had seven sexual partners in the past. She was treated for multiple sexually transmitted infections including gonorrhea, chlamydia, and pelvic inflammatory disease in her early 20's. She had an abnormal Pap test about four years ago and was treated with a LEEP. What is the most likely underlying cause of infertility in this patient?

Tubal disease

A 19-year-old G0 woman presents to the office with a two-week history of low pelvic pain and cramping. She has a new sexual partner and is on oral contraception and uses condoms. She is one week into her cycle. She has noted no vaginal discharge, itch, or odor. She denies fevers or chills. She does note that she is on a new diet and has started drinking lots of water. As such, she notes that she is urinating much more frequently. Her examination is entirely unremarkable. Which of the following is the most appropriate next step in the management of this patient?

UA

A 23-year-old G1 woman with last menstrual period 10 weeks ago presents with lower abdominal pain and vaginal bleeding two days after undergoing an elective termination of pregnancy. Her temperature is 102.0°F (38.9°C), and the cervix is 1 cm dilated. The uterus is eight-week size, tender, and there are no adnexal masses. An ultrasound shows retained products of conception. Which of the following is the most appropriate next step in the management of this patient?

Uterine evacuation + antibiotics

A 27-year-old G0 woman presents with a three-year history of dyspareunia. She reports a history of always having painful intercourse, but she is now unable to tolerate intercourse at all. She has avoided sex for the last six months. She describes severe pain with penile insertion. On further questioning, she reports an inability to use tampons because of painful insertion. She also notes a remote history of frequent yeast infections while she was on antibiotics for recurrent sinusitis that occurred years ago. Her medical history is unremarkable, and she is not on medications. Pelvic examination is remarkable for normal appearing external genitalia. Palpation of the vestibule with a Q-tip elicits marked tenderness and slight erythema. A normal- appearing discharge is noted. Saline wet prep shows only a few white blood cells, and potassium hydroxide testing is negative. Vaginal pH is 4.0. The cervix and uterus are unremarkable. Which of the following is the most likely diagnosis in this patient?

Vestibulodynia

A 45-year-old G0 woman presents complaining of a "wart" on her vulva for one year. The area has been treated several times in the past year with several applications of trichloroacetic acid in the office, as well as a 16-week course of imiquimod cream at home. The lesion never fully resolved with either treatment. On examination, an area of verrucous lesions approximately 1 cm x 1.5 cm is noted on the left labium majus near the fourchette. Upon application of 5% acetic acid, the area becomes acetowhite.The remainder of the exam is normal. A Pap test six months ago is normal. What is the most appropriate next step in the management of this patient?

Vulvar bx of the lesion

A 23-year-old G0 woman comes to the office to discuss contraception. Her past medical history is remarkable for hypothyroidism and mild hypertension. She has a history of irregular menses. Her best friend recently got a "patch," so she is interested in using a transdermal system (patch). Her vital signs are blood pressure 130/84, weight 210 pounds, height 5 feet 4 inches. What is the most compelling reason for her to use a different method of contraception?

Weight

A 55-year-old G4P4 postmenopausal woman presents for her annual examination. She complains of a pressure feeling in her vagina, particularly when she is gardening. She is not bothered by this but is concerned that something is wrong. She denies urinary incontinence. Her past medical history is significant for Ehlers- Danlos type 1 and well-controlled hypertension. She has had four vaginal deliveries. Her vitals signs are: blood pressure 138/80, pulse 70 beats/minute. Her BMI is 43 kg/m2. Her exam reveals a well-estrogenized vaginal mucosa and mild prolapse with Valsalva maneuver. What is the next best step in the management of this patient?

Weight loss

A 65-year-old G2P2 woman has a 2 cm lesion on her left labia. She describes the lesion as itching and persistent over the past three months. Her past medical history is significant for hypertension controlled with lisinopril. Her blood pressure is 140/80, heart rate 78 beats/minute, BMI is 30 kg/m2. A biopsy is performed that shows high grade VIN (vulvar intraepithelial neoplasia). Which of the following is the next best step in her management?

Wide local resection

A 42-year-old G3P3 woman comes to the office after noticing a breast mass while performing a breast self-exam. She is in good health and has normal menstrual cycles. Family history is significant for a maternal aunt with breast cancer at age 54. Physical exam reveals a 2 cm dominant breast mass. The remainder of the exam is normal. A mammogram obtained today shows no abnormalities. What is the most appropriate next step in the management of this patient?

fine needle aspiration

A 30-year-old G1P1 woman presents with a history of chronic vulvar pruritus. The itching is so severe that she scratches constantly and is unable to sleep at night. She reports no significant vaginal discharge or dyspareunia. She does not take antibiotics. Her medical history is unremarkable. Pelvic examination reveals normal external genitalia with marked lichenification (increased skin markings) and diffuse vulvar edema and erythema. Saline microscopy is negative. Potassium hydroxide testing is negative. Vaginal pH is 4.0. The vaginal mucosa is normal. Which of the following is the most likely diagnosis in this patient?

lichen simplex chronics

A 30-year-old G2P1 woman presents for a voluntary termination of her pregnancy. She reports that her last menstrual period was 10 weeks ago. She had a positive pregnancy test two days ago. She has a history of irregular periods. She is otherwise healthy and has had no surgeries. Which of the following is the next most appropriate step in her management?

pelvic US

A 20-year-old G0 woman comes to the office for her first gynecologic examination. She is requesting an etonogestrel implant. She is healthy, and her review of systems is negative. Her family history shows that her maternal grandmother died from breast cancer at age 75. Her last menstrual period was three weeks ago. She reports that she smokes half a pack of cigarettes per day and denies use of alcohol. She is currently sexually active with her boyfriend, using condoms for contraception. Blood pressure is 100/60, pulse, 75, respirations, 18 and her BMI is 22. Her pelvic exam is normal. Which of the following tests should be performed prior to proceeding with placement of the implant?

pregnancy test